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Optometric Physicians of Middle Tennessee – Hendersonville
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2017-07-06T01:14:26+00:00
Optometric Physicians of Middle Tennessee - Hendersonville
Patient Registration
Title
Dr.
Mr.
Mrs.
Ms.
Miss
Marital Status
Name
*
First
Last
Preferred Name
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone
*
Work Phone
Cell Phone
Email
*
Sex
Male
Female
Other
Date of Birth
*
MM slash DD slash YYYY
Social Security Number
Occupation
Employer
Employer Phone
How did you hear about our office?
If you were referred by a professional, please provide their contact information
Spouse's Name
Date of Birth
MM slash DD slash YYYY
SS#
In Case of Emergency, Contact
Name
First
Last
Relationship
Home Phone
Work Phone
Insurance
Who is responsible for this account?
Relationship to Patient
Date of Birth
MM slash DD slash YYYY
SS #
Insurance Company
Group Number
Is patient covered by additional insurance?
Yes
No
Subscriber Name
Date of Birth
MM slash DD slash YYYY
SS #
Relationship to Patient
Insurance Company
Group Number
Assignment and Release
I, the undersigned certify that I (or my dependent) have insurance coverage with the insurance listed above and assign directly to Optometric Physicians of Middle Tennessee all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions.
Signature
*
Medical Authorization
I request that payment of authorized Medicare benefits be made on my behalf to Optometric Physicians of Middle Tennessee for services furnished me by Optometric Physicians of Middle Tennessee. I authorize any holder of medical information about me to release to the Division of Medicare and Medicaid Services and its agents any information needed to determine those benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier.
Signature
*
Health History Questionnaire
Your Primary Care Physician
Physician's Phone Number
When was your last Health exam?
When was your last Eye Exam
History of Major Illnesses/Injuries
History of Surgeries
Surgery
Date
Surgeon
Current Medications & Eyedrops
Reason for taking
Drug Allergies
*
Your Current Eye Symptoms
Glaucoma
Cataract
Macular Degeneration
Retinal Detachment
Color Blindness
Headaches
Glare/light sensitivity
Tired Eye
Lazy Eye
Burning
Dryness
Excess Tearing
Eye Pain or Soreness
Foreign Body Sensation
Infection of Eye
Itching
Mucous Discharge
Droopy Eyelid
Redness
Sandy or Gritty Feeling
Crossed Eyes
Blurred Vision Distance
Blurred Vision Near
Distorted Vision
Double Vision
Floaters or Spots
Fluctuating Vision
Loss of Vision
Loss of Side Vision
Your Medical History
Allergies (seasonal)
Excessive Weight Loss/Gain
Ears, nose, throat
High Blood Pressure
High Cholesterol
Asthma/Breathing Problems
Stomach Problems
Arthritis/Breathing Problems
Skin (acne, rashes, etc.)
MS/Seizures
Anxiety, depression
Kidney Problems
Diabetes
Thyroid Problems
Anemia/Blood Disorders
HIV/Herpes/Lyme
Cancer
Are you pregnant/nursing?
Type of Cancer
Other
Your Social History
Current Occupation:
Do you use a computer?
If yes, how many hours a day?
Do you wear glasses?
If yes: Full time or Part time? Type of glasses owned?
Do you wear contacts?
If yes: what type?
Exercise
If yes: How many times per week?
Do you use vitamins?
Yes
No
Drink Alcohol?
If yes: Drinks per week?
Smoke?
If yes: How much?
Hobbies/Interests (Circle):
Golf
Tennis
Baseball
Fishing
Hiking
Jogging
Other
Patient Signature
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